Non-technical error leading to patient fatalities in the Australian surgical population

Many surgical adverse events are due to errors in non-technical skills (NTS); consequently, improving NTS is a priority. However, evidence to guide NTS improvement activities is lacking. This study aimed to investigate the incidence and characteristics of non-technical errors linked to fatalities in a large, representative surgical-patient population to guide future NTS improvement.

All fatality cases with known or suspected adverse events reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2012 and 2019 were retrospectively assessed using a validated tool developed by the study authors. Outcomes included the incidence of non-technical errors linked to death (overall and by NTS domain), the identification of non-technical error predictors through multivariate analysis, and change in non-technical error incidence over time using statistical process control charts.

Some 30 971 cases of surgical fatality were reported between 2012 and 2019, of which 3829 met the inclusion criteria. Due to insufficient information, 134 were excluded, leaving 3695 for analysis. Non-technical errors associated with patient death were identified in 63.7%. Of these, 58.4% had Decision-Making errors, 56.4% had Situational Awareness errors, 15.2% had Communication/Teamwork errors, and 5.44% had Leadership errors. Statistically significant predictors of Communication/Teamwork, Decision-Making, and Situational Awareness errors were identified. The incidence of overall non-technical errors decreased significantly between 2012 and 2019 and periods of significant decrease in Communication/Teamwork and Leadership errors were demonstrated. No significant decrease in Decision-Making or Situational Awareness errors were demonstrated.

The incidence of non-technical errors associated with surgical mortality rate is high. Future NTS improvement efforts should be targeted towards Decision-Making and Situational Awareness errors.